FROM MODERN HEALTHCARE: 7 years after Katrina, Sandy teaches hospitals more lessons on surviving nature

By Melanie Evans and Joe CarlsonCrain News Service

When superstorm Sandy made landfall on the Jersey shore, hospital executives were prepared for a mass influx of patients, a short-term loss of power from electric utilities, and the need to let their employees sleep on-site rather than drive home in blasting wind and rain.

But the hours and days immediately after the storm revealed that some hospitals were not prepared for the damage wrought and millions of people and businesses without power.

Four hospitals in New Jersey and New York were forced to evacuate and close their doors after floodwaters damaged backup generators needed to run elevators, lights and ventilators. Those well-publicized failures are already raising questions about the rules on where generators are located.

Meanwhile, other hospitals found themselves struggling to handle the swell in demand after a pervasive lack of electricity left patients unable to see primary physicians, receive home health care or get drugs at pharmacies, because many hospitals saw their electricity restored before other power customers.

"Interestingly, the biggest challenge is not running the hospital," said Steven Littleson, president of Jersey Shore University Medical Center, Neptune, N.J., which did not lose power but was near some of the hardest-hit communities. "The biggest challenge is making up for the other services that are not available in the community. That is what we are working through now."

The medical center set up one dedicated service area for community residents who needed prescriptions. Another was established for patients needing oxygen. The hospital has taken on dialysis patients whose normal clinics are without power, and quadriplegics who can't stay at home but can't get services in shelters that don't have power.

Littleson admitted the hospital had not prepared to become the region's major primary-care and social-services provider. "If there is a lesson here, it is to gear up for a broader array of primary-care services, post-event."

The larger toll of the storm continued to mount as the week went on.

As of Nov. 2, the death toll from the storm was nearing 100 people in the U.S. and another 71 people in Haiti and other Caribbean nations, according to the Associated Press and other media accounts.

Sandy left 8.5 million homes and businesses without power, which the U.S. Energy Department said was more than almost any other storm in U.S. history, according to the AP. The storm brought 14-foot sea surges to New York City and sustained winds above 85 mph across some of the most densely populated areas of the country. HHS Secretary Kathleen Sebelius declared a public health emergency in New Jersey and New York state.

Moody's Analytics estimated the storm created about $50 billion in losses, making it likely the second-most expensive storm in the U.S. history after Hurricane Katrina in 2005.

Bellevue Hospital, one of the nation's oldest public hospitals, was crippled and then closed by the storm, forcing an evacuation of the Manhattan facility in the days after Sandy caused its basement to flood with 17 million gallons of water.

Bellevue was one of eight hospitals in New York and New Jersey forced to evacuate by the storm, including an emergency evacuation when backup generators failed at NYU Langone Medical Center in lower Manhattan that left staff scrambling to move patients down darkened stairwells hours after the storm made landfall.

As some hospitals closed, others prepared to take in patients being shuttled across the city by adapting space for critically ill patients in areas not designed for them. And the New York State Health Department said receiving hospitals would not be penalized if they exceeded capacity.

Half of the hospitals that evacuated did so before the storm. Two Manhattan hospitals and one in Long Beach, N.Y., transferred patients ahead of the storm, as did the Hoboken (N.J.) University Medical Center. The VA N.Y. Harbor Healthcare System's Manhattan campus closed, as did nearby New York Downtown Hospital. Long Beach (N.Y.) Medical Center evacuated under orders from its county executive before the storm. Fear that water surging over the seawall could flood Hoboken and jeopardize the power for the medical center there prompted officials to empty its rooms.

As winds and flooding knocked out power to millions, dozens of hospitals across New Jersey, New York and Pennsylvania were forced to use backup generators.

The morning after landfall, 30 hospitals in New Jersey—roughly one-third of the state's total—were dependent on generators to keep critical equipment, such as ventilators, running. As of Nov. 1, five continued to rely on fuel- or gas-powered generators for electricity. In Pennsylvania, eight hospitals were operating on generators the day after the storm but had regained power by the end of the week.

Emergency power kept hospitals from going dark, but not entirely, leaving nurses to navigate darkened hallways at CentraState Healthcare System in Freehold, N.J., with flashlights for nearly 48 hours.

Hospitals typically limit generator capacity to meet required demand for equipment considered critical and do not have power for other operations, such as heating, air conditioning and ventilation outside of patient areas, said David Stymiest, a senior consultant at Smith Seckman Reid and chairman of the Electrical Distribution Task Force for the American Society for Healthcare Engineering.

"They're not required to, and it's incredibly expensive to do that," said Stymiest, who stressed he did not speak for either his employer or the ASHE.

But the Joint Commission urged hospitals after Hurricane Katrina to do more than required to "assure optimal safety during catastrophes" because minimum standards "can only support the power needs of a small percentage of the needed equipment and systems, or they are unable to supply power for an extended period of time."

Bayshore Community Hospital in Holmdel in northern New Jersey defaulted to generator power the afternoon of Oct. 29 and continued to operate late last week on backup power.

Tony Cava, the hospital's chief operating officer, said Bayshore's generators were built to run the hospital for five to seven days without refueling, depending on the power load of hospital equipment. "We are fortunate that we have three diesel generators that enable us to do that. We have a triple redundancy to do that," he said.

The hospital refueled its generators late last week, Cava said, and could run another five days without utility power.

Bellevue Hospital switched to generators with 725 patients in the hospital as water from the East River surged well beyond projections to flood the city-owned hospital's basement, leaving the hospital operating under conditions that made an evacuation "urgent" but "not emergent," said one of its physicians, Dr. Natalie Levy.

That flooding may have caused failures for pumps located in the basement that feed Bellevue's generator on the 13th floor.

Bellevue's breakdown—which forced hospital staff and National Guard members to haul fuel in five-gallon containers—and NYU Langone Medical Center's generator shutdown at the moment it was needed raised questions about what went wrong and the location of such critical equipment in flood-prone hospitals seven years after Katrina, when flooding knocked out hospitals' emergency power.

"It's something that happened in New Orleans, and it's a shame that it has happened again," said Bradford Gray, a health policy researcher and a senior fellow with the Urban Institute who studied hospital damage and response to the 2005 hurricane.

The Joint Commission and the CMS require hospitals to follow standards for emergency power supply that require hospitals to locate the generators, pumps and other emergency power supply equipment "to minimize the damage from flooding."

But the Joint Commission and the CMS rely on outdated versions of codes issued by the National Fire Protection Association in 2000 that lack revisions based on lessons learned during intervening years, Stymiest said.

The CMS declined an interview request, but said in a statement hospitals must meet rules for emergency power to receive payment from Medicare. Federal rules also require emergency power and lighting for a hospital's stairwells and its operating, recovery, intensive-care and emergency rooms.

"We are always looking at ways to update and improve our regulations, and we will apply our experiences with Sandy and other events to see if there are lessons there for improving the rules governing emergency preparedness," the agency said.

In New York City, where officials evacuated hospitals in 2011 before Hurricane Irene made landfall, Mayor Michael Bloomberg said during the emergency evacuation of NYU Langone that the city had been assured the hospital's backup power would work.

State health officials inspected generators ahead of the storm, he said. "Teams from the city's Health Department are at these facilities making sure their emergency generators are working and that they have backup fuel supplies," Bloomberg said as he announced mandatory evacuations of flood-prone areas of the city, but added that hospitals were largely exempt. Hospitals facing flood risk would move patients to higher floors, he said.

The mayor's office and New York's health department did not respond to interview requests.

Dr. Robert Grossman, dean and CEO of NYU Langone, said the hospital did not evacuate ahead of Sandy based on projections for the storm surge and to avoid the risks of moving recent surgery and ventilator patients and other acutely ill patients.

Floodwater rose "extremely high and extremely fast" at the hospital and breached the vault that housed underground fuel tanks, though the vault was designed to withstand flooding, said Richard Cohen, vice president for facilities management for the medical center.

That prompted safety sensors to shut down pumps that carry fuel to the hospital's rooftop generators, which were installed about four years ago. New York City rules say fuel tanks must be located below ground or at a building's lowest level, he said. Fuel pumps are located near fuel tanks for a number of reasons, he said.

NYU Langone will bring in outside experts to analyze the system failure and review the medical center's own analysis of what went wrong.

Gary Cohn, the president of Goldman Sachs and a trustee at NYU Langone, told Bloomberg TV: "I am acutely aware that the infrastructure at NYU is somewhat old," he said. "We do have backup generation facilities. They are not state-of-the-art, they're not in the most state-of-the-art location. That's all very, very well-known by the board of directors of NYU."

The hospital's namesake, billionaire Kenneth Langone, who was hospitalized at the facility during the storm, defended NYU Langone's preparations. "We believed we had the machines, we believed the machines would work, and we believed everything we were told about the scope and size of the storm," he told Bloomberg News.

Officials at Bellevue did not yet know the cause of the fuel pump failure there. Floodwater may be to blame but so may an issue with power lines to the fuel pumps, said Alan Aviles, president and CEO of the New York City Health and Hospitals Corp., which owns Bellevue.

Bellevue was expected to be closed for two or three weeks, if not longer, according to early projections. NYU Langone said last week in a statement it was too soon to know when it would reopen.

Generators at the Health and Hospital Corp.'s Coney Island Hospital in Brooklyn, which was also evacuated after the storm, are located above ground by a couple of feet and advancing floodwater forced the hospital to turn them off to prevent damage, leaving the hospital in the dark for four hours, Aviles said.

A system spokesman said flood projections did not suggest either hospital's generators were at risk, but water levels later exceeded expectations.

New Orleans hospitals took flooding during Katrina to heart. "All the generators have been moved up and are protected from floodwaters," said John Matessino, president and CEO of the Louisiana Hospital Association. In addition, "We've improved our generators so that they'll run some, if not all, of their HVAC systems," Matessino said.

But he's not pointing fingers at the Northeast, which doesn't get the hurricane activity that Louisiana does, having seen four since Katrina in 2005. "They don't think about them as much," he said.

In Atlantic City, near where Sandy made landfall, AtlantiCare Regional Medical Center moved its generator last year from ground level to the third floor to better prepare for potential flooding. The move was made based on the hospital's prior experience with storms and experiences of other hospitals, a spokeswoman said.

But hospitals are not generally required to relocate generators, only to adhere to standards in place when they were built, the ASHE's Stymiest said.

Dr. David Marcozzi, director of the Hospital Preparedness Program within HHS' Office of the Assistant Secretary for Preparedness and Response, said hospital executives have to consider the cost of moving existing generators as well as how big a generator they can afford to buy and maintain. "It's a balancing act of what is the biggest generator they can buy, and how much can they afford," Marcozzi said. "It's a little bit of a gamble."

Hospitals that did not lose power or those that regained it in darkened communities quickly became more than a source of acute medical care.

At CentraState Healthcare System in New Jersey, which regained its power more quickly than its neighbors, the hospital's cafeteria now doubles as a restaurant, its fitness center's showers are open to the public, and some residents and staff have recharged dying cell phone batteries using the hospital's outlets, said Abbey Luterick, a system spokeswoman.

Most of the dozen hospitals in Sandy's path contacted for this story said they made plans for staff to sleep on-site during the storm.

Virtua, a four-hospital system based in Marlton in south New Jersey, provided impromptu sleeping quarters for more than 400 of its employees. The system had prepared to house workers on-site because of fears about difficulties in getting back home during a major storm.

Employees slept on cots in outpatient areas and in conference rooms. Other hospital systems reported using cafeterias, nursing stations, and other areas for sleeping.

"Folks were really prepared to stick it out for a long time," said Michael Kotzen, Virtua's executive vice president for population health management.

Paul Lambrecht, vice president of clinical and support services at Underwood-Memorial Hospital in the south New Jersey city of Woodbury, said communicating with his staff proved one of the best ways to keep employees feeling as secure as possible. The hospital used e-mails, text messages and recorded messages on a call-in line to give workers real-time updates about the storm's progress and the hospital's status.

"You can never over-communicate" in a disaster situation, Lambrecht said.

But many hospital officials said one of the biggest challenges of the night was keeping their focus on the job while knowing that their loved ones were in the storm without them, and their houses might be taking on the kind of damage they were seeing on the news.

"Everybody has a story like that," said Dr. Sachin Shah, director of emergency services at Nyack (N.Y.) Hospital, about 20 miles north of New York City. "Because it's so busy, you focus on the patients that are in front of you instead of letting your mind wander to what's going on at home."

Mark Solazzo, COO of North Shore-Long Island Jewish Health System, based in Great Neck, N.Y., knew full well that his own house was being swamped even as he sat inside the health system's command center monitoring updates from the system's 11 hospitals along the Atlantic Coast.

By the night of Oct. 30, the storm left Solazzo's entire staff needing rest, their acute-care beds stuffed at surge capacity, and most of the system's hospitals relying on diesel generators to keep the lights on. The system had already started making arrangements to help employees' families to get loans or cash out their accruals.

But he had a personal crisis to attend to. Although his family and his elderly parents had been safely ensconced in a hotel, a pet cat had somehow been left behind in his parents' home—which had already taken on more than a foot of standing water. So he went and rescued the cat.

"Our hospital is safe, the patients are safe, my family is safe," Solazzo said. "The rest is material. It will get itself back in place over time."

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